GW1-2022-08581_Well Construction - GW1_20220517

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: \\
La n I `m V\�`1 l 1 V 1 V` IV 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
NC Well Contractor Certification Number I&OUTER CASING(for multi-cased wells)OR LINER(if a Gcable)
\ \ 11 'i11' FROM TO DIAMETER THICKNESS M(A�TERIAL
y�1 �—� fL 90 ft. �` in. i'v�
� � � e ► ► cam
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# V" 1 ®`1`+ 1 �* FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): et. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public �t. �ft. in. S" 1,�w K(_.�
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. in,
❑Industrial/Commercial kiesidential Water Supply(shared) -18.GROUT ,
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. £t. ors
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage O
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
0 ft. a ft. v e
4.Date Well(s)Completed:1� 2\ Well ID# OL
5a.Well Location: Yr1 r�/�/y ®��n _W h 1' e O cL
`r�RVN DX 95 L11�1 1 14L►„� � ft. 6 l3 ft. A
acilityy//jOwnerName i ,^ , ,nFla�cilliityID#�(i`fa)pplicable)�j ` ft. ft.
/ A 1 .� 1 1 V1Y 111Y iV 1. �O l� ft. fL �"` 9.-.
„^°
Physical Address,City,and Zip ft. ft. v r'
2r1.�R,CEMARKS, -u
County Parcel Identification No.(PIN) Cogs 1
nJ
5b.Latitude and longitude in de degrees:g degrees/minutes/seconds or decimal de — ^"""'"'
(if well field,one hit/long is sufficient) 22.Certification: vy ' I'
r C�S�-'a�P N `93 , 5991 2 w o
6.Is(are)the well(s): L4ermanent or ❑Temporary Signature of Ce ed Well Contractq• Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orp 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information an/d explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: aC (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200:and 2 @I00')
l� 24a. For All Wells: Original form to Division of Water Resources (DWR),
If Static water level below top of casing: I (ft.) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"{"
f�(^/ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
11.Borehole diameter: q (in.) Program,1636 MSC,Raleigh,NC 27699-1636
�12.Well construction method: 3_t T nA 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: 1 f�6
Permit Program,1611 MSC,Raleigh,NC 27699-1611
75 U�YI
1
13b.Disinfection type: Amount:
Form GWA North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018